Provider First Line Business Practice Location Address:
2901 KOOTENAI ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83705-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-343-4855
Provider Business Practice Location Address Fax Number:
208-343-4856
Provider Enumeration Date:
08/15/2006